Carilion Roanoke Community Hospital

Attention is called to a hitherto largely overlooked manifestation of fibrous dysplasia. Nine previous cases and 2 new cases of intramuscular myxomas in cases of fibrous dysplasia are reviewed. Ten of the 11 cases had multiple intramuscular myxomas, usually on the right side, and all near but distinct from the bony lesions. All were benign. In 5 cases with Albright's syndrome, the multiple myxomas occurred on the same side as the cutaneous pigmentations. Characteristically, the myxomas made their appearance considerably later in life than the fibrous dysplasia. The literature is reviewed, and the probable pathogenic relationship between myxomas and fibrous dysplasia is discussed.

Opsoclonus-myoclonus syndrome (OMS) is an autoimmune disorder with serious neurodevelopmental morbidity and limited treatment options. We treated a toddler with moderately severe OMS with rituximab, a monoclonal anti-B cell antibody. The patient's clinical response was documented on videotape and scored with the OMS Evaluation Scale. Cerebrospinal fluid lymphocyte subsets were evaluated by flow-cytometric immunophenotyping, with a comprehensive panel of monoclonal antibodies. Eradication of cerebrospinal fluid B cells, which previously were expanded, was associated with dramatic clinical improvement. There also were secondary changes in other lymphocyte subsets that might be relevant to the clinical response and lack of serious infections. In addition to clarifying the immune response to B-cell depletion, these data reveal a promising new therapy for OMS that warrants a phase I clinical trial.

A single report of brothers born to first-cousin parents with a form of acute spinal muscular atrophy (SMA) and congenital fractures suggested that this combination represented a distinct form of autosomal recessive SMA. We describe a boy with hypotonia and congenital fractures whose sural nerve and muscle biopsies were consistent with a form of spinal muscular atrophy. Molecular studies identified no abnormality of the SMN(T) gene on chromosome 5. This case serves to validate the suggestion of a distinct and rare form of spinal muscular atrophy while not excluding possible X-linked inheritance.

OBJECTIVE: To determine predicted utilization, decrease in ambulance transports, and target population for emergency medical services (EMS) if telemedicine capabilities were available to the medic units in the field. METHODS: A retrospective chart review of 345 consecutive ambulance transports to four hospitals (Level I urban trauma center, urban tertiary care center, children's hospital and suburban community hospital) was performed by a panel of three board-certified emergency medicine physicians experienced and credentialed in emergency telemedicine. They independently reviewed the emergency department (ED) and EMS records and were asked to determine whether patients required ambulance transport for evaluation or whether disposition could be made following paramedic and emergency physician assessment via telemedicine. A five-point Likert scale was used to grade feasibility of telemedicine disposition (definitely yes, probably yes, maybe, probably no, definitely no). Other variables analyzed included age, sex, race, chief complaint, phone, private medical doctor, and call location by patient zip code, call site, and receiving hospital. RESULTS: In 14.7% of cases (6% definitely yes and 8.7% probably yes), disposition could be made without transport using telemedicine. The age range for eliminating transport was 2 weeks through 92 years, with mean age of 26.6 years. Under the age of 50 years, 46 out of 238 patients (19.3%) could have possibly been managed by telemedicine. CONCLUSION: Use of EMS telemedicine could result in an approximately 15% decrease in ambulance transports when it alone is added to the prehospital care provider's armamentarium. Emphasis for implementation should be placed on younger patients and an identified subset of chief complaints conducive to management using telemedicine.

Advances in medical science and, in particular, minimally invasive surgical and diagnostic procedures have stimulated the development of new and improved medical devices. This has been made possible because of developments in engineering and material sciences. The design of devices for reusability is particularly important in an effort to provide cost effective healthcare. Concerns and issues include the ability to safely and effectively reprocess the devices, infection prevention and control, safety of the patient and healthcare worker, environmental concerns, and effective use of resources. From an infection prevention point of view, present requirements are based upon the intended use of the devices. Critical devices require sterilization. Semi-critical devices require, as a minimum, high level disinfection. Sterilization is, however, preferred whenever possible. Before sterilization or disinfection, devices should be cleaned adequately. Device designs should be readily amenable to cleaning and sterilization. In the past, design requirements focused primarily on the clinical user and device functionality, with reuse considerations left to the user. In the current market, the customer is redefined and, for reusable medical devices, includes all those associated with the device through the reprocessing procedure. In addition, regulations require that manufacturers give detailed instructions for reprocessing medical devices. The device users have the obligation to follow reprocessing instructions. Many choices exist today in device designs, including disposable or reusable devices. The user needs to balance cost versus convenience and reprocessing requirements for reusables. Current trends are to reuse more devices, including many of which were meant to be disposable. Cost effective designs can best be achieved when the user and manufacturer work together on the design. Concerns for infection prevention and control are highlighted by the continual spread of hepatitis B, HIV, and resistant strains of tuberculosis and bacterial species. This places particular emphasis on the selection of sterilization/disinfection processes for reusable medical devices and emphasizes the need for sterilization. It is clear that to achieve the best quality of healthcare in a cost conscious environment, reusable medical device designs are practical. To achieve the best desired results, a partnership of the manufacturer and user is required.ASAIO Journal1995;41:146-151.

RATIONALE: Predicted increases in heat-related weather phenomena will result in increasing heat exposures and heat injuries, like heat stroke. Prompt recognition, early intervention, and evidence-based management are necessary to optimize outcomes. OBJECTIVES: The objective of these guidelines was to develop evidence-based recommendations for the treatment of patients with heat stroke. DESIGN: The Society of Critical Care Medicine convened a multidisciplinary panel of 18 international clinicians, comprising expertise in critical care, emergency medicine, neurocritical care, surgery, trauma/burn surgery, sports medicine, athletic training, military medicine, nursing, pharmacy, respiratory therapy, and one patient representative. The panel also included a guidelines methodologist specialized in developing evidence-based recommendations in alignment with the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology. Conflict-of-interest policies were strictly followed during all phases of guidelines development including panel selection and voting. METHODS: The panel members identified Patient, Intervention, Comparison, and Outcomes questions in two main areas: cooling modalities and medications that affect temperature. A systematic review for each question was conducted to identify the best available evidence, statistically analyze the evidence, and assess the certainty of the evidence using the GRADE methodology. The GRADE evidence-to-decision framework was used to formulate the recommendations. Good practice statements were included to provide additional clinical guidance. RESULTS: The panel generated two strong recommendations, five good practice statements and one "only-in-the-context of research" statement. Active cooling measures are recommended over passive cooling methods, with cold- or ice-water immersion achieving the fastest cooling rate. This method should be prioritized where available. In heat stroke patients, there is no evidence to support pharmacological interventions that affect temperature control and they should be avoided. CONCLUSIONS: The guidelines task force provided recommendations for the management of patients with heat stroke. These recommendations should be considered along with the patient's clinical status and available resources.

This report describes the sonographic diagnosis of the Pena-Shokeir syndrome type 1 during the second trimester of a pregnancy which was electively terminated. The mother had previously delivered a macerated, hydropic infant with multiple congenital anomalies. The diagnosis was based on the recurrence of hydramnios and nonimmune hydrops in a fetus with normal chromosomes, normal amniotic fluid alpha-fetoprotein, normal fetal echocardiography, and lack of evidence of a lysosomal storage disease. These observations suggest that serial sonography during the second trimester in pregnancies at risk may allow for the prenatal diagnosis of the Pena-Shokeir syndrome type 1. Without further experience, it would not be prudent to suggest to couples at risk that the prenatal diagnosis of a recurrence can be assured with a high degree of accuracy.

OBJECTIVES: The charge of the newly formed Society of Critical Care Medicine Sustainability Task Force is to describe actionable items supporting environmental stewardship for ICUs, to discuss barriers associated with sustainability initiatives and outline opportunities for future impact. DATA SOURCES: Ovid Medline, EBSCOhost CINAHL, Elsevier Embase, and Scopus databases were searched through to March 2024 for studies reporting on environmental sustainability and critical care. STUDY SELECTION: Systematic reviews, narrative reviews, quality improvement projects, randomized clinical trials, and observational studies were prioritized for review. Bibliographies from retrieved articles were scanned for articles that may have been missed. DATA EXTRACTION: Data regarding environmental sustainability initiatives that aimed to quantify, manage, or mitigate pollution and/or carbon emissions with a focus on ICUs, barriers to change, and opportunities for development were qualitatively assessed. DATA SYNTHESIS: ICUs are resource-intensive and as such, methods to attenuate carbon emissions and waste can play a substantial role in mitigating the sizable burden of healthcare-related pollution and greenhouse gas emissions. Several initiatives and strategies exist for clinicians and providers to engage in environmental stewardship, with specific attention to avoiding low-value care while maintaining or improving patient safety and high-quality care. Increased focus on sustainability can be met with resistance to change, including institutional, financial, and behavioral barriers. Collaboration and innovative thinking create valuable opportunities for clinicians, patients, families, and policymakers to advocate for patient and planetary health. CONCLUSIONS: Within the healthcare system, ICUs are well positioned to lead sustainability action, policy, and practice. Critical care teams have the capability and the moral responsibility to mitigate the negative impact of critical care medicine upon our environment and become change agents promoting sustainable healthcare for the benefit of human health.

BACKGROUND: The quality of care for asthma remains suboptimal. Compliance with guidelines remains low, but improved adherence to guidelines may increase the quality of care. but. We conducted a trial to determine whether group Self-Assessment Module (SAM) activities led by a facilitator and conducted as part of Maintenance of Certification for Family Physicians (MC-FP) would increase knowledge of and adherence to asthma guidelines. METHODS: Participating physicians completed audits of the charts of patients with asthma before and 6 months after a group SAM. Surveys of physicians' knowledge of asthma guidelines were administered immediately before, immediately after, and 6 months after the group SAM. We tested for differences in knowledge of and adherence to guidelines before and after the SAM using χ(2) and t tests. RESULTS: Thirty-eight physicians in Virginia completed the SAM and had complete data. Participants completed more MC-FP activities than other physicians but were comparable in other characteristics. Except for prescribing controller medications for persistent asthma, all other quality measures significantly improved 6 months after the group SAM. Diagnosis by severity improved from 48.3% to 80.2%, and the use of action plans increased from 8.1% to 54.1%. Physicians' knowledge of guidelines improved immediately after the SAM and was sustained at 6 months. Increased knowledge translated into clinical skills: 30% of participants reported comfort with assessing control after the SAM, which increased to 97.5% 6 months after the SAM. CONCLUSIONS: Group SAMs may be an effective method to increase physicians' knowledge of and adherence to clinical guidelines.

OBJECTIVE: To determine whether the distribution of peripheral blood mononuclear cells (PBMCs) is altered in paraneoplastic opsoclonus-myoclonus (POM). METHODS: PBMCs from 17 children with POM, 17 children with OM but no tumor, and 17 controls were immunophenotyped using a comprehensive panel of surface markers by dual-laser flow cytometry. All groups were matched for age and gender; POM and OM patients were matched for treatment. RESULTS: In the POM patients, the CD4+ T-cell subset was smaller in both relative size (-18%, P = 0.02) and absolute size (-41%, P = 0.03) compared with controls. The CD4/CD8 ratio also was less (-29% to -44%) and was related to POM duration (P = 0.03). The absolute but not relative size of the gammadelta T-cell subset was reduced (-44%, P = 0.02). There were no significant abnormalities of CD19+ B-cells, CD3- or CD3+ NK cells, HLA-DR+ or CD25+ T-cells, or CD45RA+ or CD45RO+ T-cells. Prior tumor chemotherapy, which was associated with a higher percentage but not number of CD8+ T-cells, did not restore the CD4+ T-cell subset. When the POM and OM groups, which were not significantly different, were combined, chemotherapy decreased both the relative and absolute size of the CD19+ B-cell pool and had small effects on other lymphocyte subsets. CONCLUSIONS: POM is characterized by T-cell abnormalities of PBMCs, the most robust of which is reduction of the CD4+ T-cell subset and the CD4/CD8 ratio. Although this reduction was found previously in cerebrospinal fluid in POM patients, PBMC subsets did not otherwise reflect cerebrospinal fluid abnormalities. Longitudinal studies will be necessary to determine whether PBMC abnormalities could serve as treatment markers.

OBJECTIVE: The objective of this study was to determine the feasibility (i.e., limited efficacy testing, practicality, and acceptability) of a 6-week smartphone game-based applications program for promoting physical activity (PA) in adolescents in an afterschool program. MATERIALS AND METHODS: This mixed-method, quasi-experimental design study included 27 adolescents who evaluated four smartphone PA game-based applications in two Boys & Girls Clubs of America. After an initial baseline week (i.e., usual activity during their visit to the Club), adolescents played each game for 1 week. During a final week, the participants could choose to play any combination of the four games. An established conceptual framework was used to assess feasibility. Efficacy was assessed by changes in PA via wrist-worn accelerometers (model GT3x+; ActiGraph LLC, Pensacola, FL). Practicality was measured through field notes, the number of players attending each session, and the proportion of attendees who played the games. Acceptability was measured using poststudy focus groups. RESULTS: Compared with baseline (3.22 metabolic equivalents [METs]), mean accelerometer values were significantly (P<0.05) higher during "Space Rayders" (4.33 METs) and "Color Hunt" (3.67 METs). Attendance did not differ among games, and weekly number of players averaged 12 of 27 participants. Qualitative findings indicated that participants perceived "Space Rayders" as the most acceptable game. Overall, participants found the games to be enjoyable and easy to use, although they had suggestions to improve graphics and sounds. CONCLUSIONS: Smartphone games can be feasible for adolescents to use for PA. Lessons learned will be used to provide improvements for future game development and evaluation.

Recurrent episodes of endoscope contamination with nontuberculous mycobacterium and Pseudomonas species, coupled with employee concerns about exposure to 2% glutaraldehyde and the requirement for rapid scope turnover time, led to the investigation of an alternative method for endoscope processing. A prospective evaluation of 220 bronchoscopy procedures was carried out. Endoscope culture surveillance was performed twice a month for a 12 month period on all endoscopes. In addition, the deliberate inoculation of bronchoscopes with Mycobacterium gordonae was carried out. No indications of cross contamination were noted among the 220 bronchoscopy procedures after processing the scopes by the studied liquid chemical sterilization system using peracetic acid. Ongoing patient surveillance did not reveal any indications of cross contamination for nearly 15,000 patients diagnostic or surgical endoscopic procedures using instruments processed by this liquid chemical sterilization system. Twice a month for 12 months, bronchoscopes, colonoscopes, and gastroscopes were cultured for bacterium, fungi, and acid fast bacilli and showed no growth. Deliberate inoculation of bronchoscopes with M. gordonae showed the scopes were rendered sterile. No unusual occurrences of occupational chemical exposure were found in 11 individuals working with this liquid chemical sterilization system. The peracetic acid based sterilization system studied proved to be an effective, safe, and economical alternative to the glutaraldehyde method.

A 17 year old girl with active Crohn's colitis developed idiopathic thrombocytopenic purpura that was managed with intravenous immune globulins and cyclosporin A. The possible association between Crohn's disease and immune thrombocytopenia is explored.

Recurrent episodes of endoscope contamination with nontuberculous mycobacterium andPseudomonasspecies, coupled with employee concerns about exposure to 2% glutaraldehyde and the requirement for rapid scope turnover time, led to the investigation of an alternative method for endoscope processing. A prospective evaluation of 220 bronchoscopy procedures was carried out. Endoscope culture surveillance was performed twice a month for a 12 month period on all endoscopes. In addition, the deliberate inoculation of bronchoscopes withMycobacterium gordonaewas carried out. No indications of cross contamination were noted among the 220 bronchoscopy procedures after processing the scopes by the studied liquid chemical sterilization system using peracetic acid. Ongoing patient surveillance did not reveal any indications of cross contamination for nearly 15,000 patient diagnostic or surgical endoscopic procedures using instruments processed by this liquid chemical sterilization system. Twice a month for 12 months, bronchoscopes, colonoscopes, and gastroscopes were cultured for bacterium, fungi, and acid fast bacilli and showed no growth. Deliberate inoculation of bronchoscopes withM. gordonaeshowed the scopes were rendered sterile. No unusual occurrences of occupational chemical exposure were found in 11 individuals working with this liquid chemical sterilization system. The peracetic acid based sterilization system studied proved to be an effective, safe, and economical alternative to the glutaraldehyde method.ASAIO Journal1995;41:151-154.

We have found in reviewing our vascular cases that the Fogarty embolectomy is definitive treatment in only certain types of cases; in most it is an adjunct to more complex vascular surgery. In our cases, an embolectomy catheter was used as an integral part of the procedure in 130 (18%) cases. In 96 (74%) cases, an embolectomy alone was performed with a success rate of only 48% (46 cases). In 50 (52%) cases, the embolectomy was not adequate, requiring reoperation, a new bypass, or amputation within 7 to 10 days. Mortality rate for the series of 130 patients was 7.0%, and limb loss rate was 5.0%. The majority of cases (92) in this review were diagnosed with an acute exacerbation of diffuse peripheral vascular disease or a clotted graft, and it is in these patients that the success rate was so poor (17%) if embolectomy alone was performed. The population of patients presenting with suspected acute arterial insufficiency has changed over the past 30 years. Now it is the elderly who have an acute exacerbation of their peripheral vascular disease. It is this change in the population that has made the Simple Fogarty Embolectomy an operation of the past--mandating angiography, Fogarty embolectomy, and complex vascular reconstruction for limb salvage.

Iliac artery aneurysm rupture can be rapidly fatal if not diagnosed immediately. These aneurysms usually present in patients with other aneurysmal diseases of the aortoiliac arterial system. If not diagnosed and surgically repaired, iliac artery aneurysms can proceed to expand and ultimately rupture, usually presenting with back, flank, or abdominal pain and, possibly, signs of systemic shock. We present an unusual case report of a common iliac artery aneurysm rupture presenting as gross hematuria due to an arteriovesical fistula. Only three other cases of arteriovesical fistulae have been reported previously. Unlike the case presented, all three of these cases involved trauma or surgical instrumentation or manipulation of the bladder.

Carotid endarterectomy has recently become one of the more controversial operations. The tremendous increase in the number of endarterectomies performed, coupled with the apparent increase in morbidity and mortality associated with this operation in some studies, have brought into question the indications and results of the procedure. The potential for complications from the procedure itself, as well as increased morbidity and mortality from surgery on the elderly, make carotid endarterectomy a dangerous operation that must be done carefully and thoughtfully. The authors have performed carotid endarterectomies exclusively under local anesthesia to more closely evaluate the neurologic status of the patient. They believe that the operation performed in this manner obviates the use of a shunt and its inherent complications in greater than 80 per cent of the patients. This, coupled with the fact that many of the patients also have severe cardiac disease and the use of local anesthesia causes less hemodynamic changes and stress, should make carotid endarterectomy under local anesthesia the preferred approach.

Abstract The purpose of this study was to explore the relationship between tactile defensiveness and self‐esteem in typical children attending a state school. Thirty‐two children aged 8–11 were administered the Touch Inventory for Elementary School Aged Children to measure tactile defensiveness, and the Piers Harris Self Concept Scale to measure self‐esteem. A Spearman rank order correlation coefficient revealed a negative correlation (−0.429) which was statistically significant (p=0.014). These findings suggest that there is an inverse relationship between self‐esteem and behaviours associated with tactile defensiveness in elementary‐school‐aged children. Continued research in this area is recommended. Copyright © 1998 Whurr Publishers Ltd.

Brief Communications1 July 1994The Hepatopulmonary Syndrome Masquerading as Pulmonary Langerhans-Cell HistiocytosisStephen H. Caldwell, MD, Kenneth Brantley, MD, John Dent, MD, Robert C. Keeley, MD, Timothy Pruett, MD, John F. Angle, MD, Michael Gaffey, MD, and Peter Waldron, MD, and Hepatopulmonary Syndrome Study Group.Stephen H. Caldwell, MDFrom the University of Virginia Health Sciences Center, Charlottesville, Virginia, and Community Hospital of the Roanoke Valley, Roanoke, Virginia.For members of the Hepatopulmonary Syndrome Study Group and current author addresses, see end of text.Search for more papers by this author, Kenneth Brantley, MDFrom the University of Virginia Health Sciences Center, Charlottesville, Virginia, and Community Hospital of the Roanoke Valley, Roanoke, Virginia.For members of the Hepatopulmonary Syndrome Study Group and current author addresses, see end of text.Search for more papers by this author, John Dent, MDFrom the University of Virginia Health Sciences Center, Charlottesville, Virginia, and Community Hospital of the Roanoke Valley, Roanoke, Virginia.For members of the Hepatopulmonary Syndrome Study Group and current author addresses, see end of text.Search for more papers by this author, Robert C. Keeley, MDFrom the University of Virginia Health Sciences Center, Charlottesville, Virginia, and Community Hospital of the Roanoke Valley, Roanoke, Virginia.For members of the Hepatopulmonary Syndrome Study Group and current author addresses, see end of text.Search for more papers by this author, Timothy Pruett, MDFrom the University of Virginia Health Sciences Center, Charlottesville, Virginia, and Community Hospital of the Roanoke Valley, Roanoke, Virginia.For members of the Hepatopulmonary Syndrome Study Group and current author addresses, see end of text.Search for more papers by this author, John F. Angle, MDFrom the University of Virginia Health Sciences Center, Charlottesville, Virginia, and Community Hospital of the Roanoke Valley, Roanoke, Virginia.For members of the Hepatopulmonary Syndrome Study Group and current author addresses, see end of text.Search for more papers by this author, Michael Gaffey, MDFrom the University of Virginia Health Sciences Center, Charlottesville, Virginia, and Community Hospital of the Roanoke Valley, Roanoke, Virginia.For members of the Hepatopulmonary Syndrome Study Group and current author addresses, see end of text.Search for more papers by this author, and Peter Waldron, MDFrom the University of Virginia Health Sciences Center, Charlottesville, Virginia, and Community Hospital of the Roanoke Valley, Roanoke, Virginia.For members of the Hepatopulmonary Syndrome Study Group and current author addresses, see end of text.Search for more papers by this author, and Hepatopulmonary Syndrome Study Group.Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/0003-4819-121-1-199407010-00006 SectionsAboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Langerhans-cell histiocytosis (which can take the form of histiocytosis X, eosinophilic granuloma, Abt-Letterer-Siwe disease, and Hand-Schuller-Christian disease) may involve the bone, lung, liver, hypothalamus, and pituitary [1]. Pulmonary failure is the leading cause of death in long-term survivors [2]. Liver involvement, seen in 65% of patients with the disease, may progress to sclerosing cholangitis and cirrhosis [1, 3, 4]. Liver biopsy specimens may show cirrhosis without active histiocyte infiltration [4]. Liver transplantation in hepatobiliary Langerhans cell histiocytosis has been reported [5]. The hepatopulmonary syndrome is characterized by intrapulmonary vasodilatation and hypoxemia in patients with portal hypertension [6, 7] and has ...References1. Berry DH, Becton DL. Natural history of histiocytosis-8. Hematol Oncol Clin North Am. 1987; 1:23-34. Google Scholar2. Komp DM. Long-term sequelae of histiocytosis-8. Am J Ped Hematol Oncol. 1981; 3:165-8. Google Scholar3. Greenberger JS, Crocker AC, Vawter G, Jaffe N, Cassady JR. Results of treatment of 127 patients with systemic histiocytosis (Letterer-Siwe syndrome, Schuller-Christian syndrome and multifocal eosinophilic granuloma). Medicine (Baltimore). 1981; 60:311-38. Google Scholar4. Leblanc A, Hadchouel M, Jehan P, Odievre M, Alagille D. Obstructive jaundice in children with histiocytosis X. Gastroenterology. 1981; 80:134-9. Google Scholar5. Rand EB, Whitington PF. Successful orthotopic liver transplantation in two patients with liver failure due to sclerosing cholangitis with Langerhans cell histiocytosis. J Pediatr Gastroenterol Nutr. 1992; 15:202-7. Google Scholar6. Daoud FS, Reeves JT, Schaefer JW. Failure of hypoxic pulmonary vasoconstriction in patients with liver cirrhosis. J Clin Invest. 1972; 51:1076-80. Google Scholar7. Krowka MJ, Cortese DA. Pulmonary aspects of liver disease and liver transplantation. Clin Chest Med. 1989; 10:593-616. Google Scholar8. Krowka MJ, Dickson ER, Cortese DA. Hepatopulmonary syndrome. Clinical observations and lack of therapeutic response to somastatin analogue. Chest. 1993; 104:515-21. Google Scholar9. Eriksson LS, Soderman C, Ericzon BG, Eleborg L, Wahren J, Hedenstierna G, et al. Normalization of ventilation/perfusion relationships after liver transplantation in patients with decompensated cirrhosis: evidence for a hepatopulmonary syndrome. Hepatology. 1990; 12:1350-7. Google Scholar10. Stoller JK, Moodie D, Schiavone WA, Vogt D, Broughan T, Winkelman E, et al. Reduction of intrapulmonary shunt and resolution of digital clubbing associated with primary biliary cirrhosis after liver transplantation. Hepatology. 1990; 11:54-8. Google Scholar11. Eriksson LS. Is intrapulmonary arteriovenous shunting and hypoxemia a contraindication for liver transplantation? Hepatology. 1991; 14:575-6. Google Scholar12. Ha SY, Helms P, Fletcher M, Broadbent V, Pritchard J. Lung involvement in Langerhans' cell histiocytosis: prevalence, clinical features, and outcome. Pediatrics. 1992; 89:466-9. Google Scholar13. Basset F, Corrin B, Spencer H, Lacronique J, Roth C, Soler P, et al. Pulmonary histiocytosis X. Am Rev Respir Dis. 1978; 118:811-20. Google Scholar14. Friedman PJ, Liebow AA, Sokoloff J. Eosinophilac granuloma of lung. Clinical aspects of primary histiocytosis in the adult. Medicine (Baltimore). 1981; 60:385-96. Google Scholar15. Marcy TW, Reynolds HY. Pulmonary histiocytosis X. Lung. 1985; 163:129-50. Google Scholar16. Krowka MJ, Cortese DA. Pulmonary aspects of chronic liver disease and liver transplantation. Mayo Clin Proc. 1985; 60:407-18. Google Scholar17. Hind CR, Wong CM. Detection of pulmonary arteriovenous fistulae in patients with cirrhosis by contrast 2D echocardiography. Gut. 1981; 22:1042-5. Google Scholar Author, Article, and Disclosure InformationAffiliations: From the University of Virginia Health Sciences Center, Charlottesville, Virginia, and Community Hospital of the Roanoke Valley, Roanoke, Virginia.For members of the Hepatopulmonary Syndrome Study Group and current author addresses, see end of text.Corresponding Author: Stephen H. Caldwell, MD, Division of Gastroenterology, Hepatology, and Nutrition, Box 145, University of Virginia Health Sciences Center, Charlottesville, VA 22908.Acknowledgments: The authors thank Ms. Chris Spillman for assistance in manuscript preparation and Dr. David Stone for his review of this manuscript. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetails Metrics Cited byOutcomes of liver transplantation in patients with hepatopulmonary syndrome in the pre and post-MELD eras: A systematic reviewHepatopulmonary Disorders: Gas Exchange and Vascular Manifestations in Chronic Liver DiseaseSyndrome hépatopulmonaire et pneumopathie interstitielle diffuse idiopathiqueLangerhans cell histiocytosisTHE HEPATOPULMONARY SYNDROMEHepatopulmonary Syndrome With Progressive Hypoxemia as an Indication for Liver Transplantation: Case Reports and Literature ReviewTHE HEPATOPULMONARY SYNDROMEHepatopulmonary syndrome: What are we learning from interventional radiology, liver transplantation, and other disorders? 1 July 1994Volume 121, Issue 1Page: 34-36KeywordsBiopsyCirrhosisLiverLiver diseasesLungsPulmonary arteriesPulmonary diseasesThoraxThyroxineVasodilation Issue Published: 1 July 1994 Copyright & PermissionsCopyright © 1994 by American College of Physicians. 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The duplex scan has become the definitive test in the diagnosis of carotid arterial disease. Its significance, however, has been diminished its extensive use for inappropriate indications. We performed a retrospective study over a four year period at two major hospitals to evaluate the different indications for carotid duplex scans. Symptoms which prompted the test, associated diseases, the type of physician ordering the test, and demographic data were recorded on all patients. Statistical analysis was used to indicate which symptoms and associated diseases were significant in predicting carotid disease. A total of 4,764 scans were reviewed. There were 4,289 studies (90%) which were negative for disease requiring surgery. There were a total of 12 indications for the carotid duplex scan in this study; the most common indications were dizziness, (20%) transient ischemic attack symptoms (19%) and a bruit (16%). Vascular surgeons (28%), Internal Medicine physicians (27%) and Family practice physicians (15%) ordered the duplex scan most frequently, but 39% of the positive scans were ordered by vascular surgeons. A history of seizures, confusion, stroke and as a preoperative evaluation all had a very low yield and should not be used as an indication for a duplex scan. However, a long smoking history, a history of known carotid disease, and peripheral vascular disease all had a statistical correlation with an abnormal duplex scan. The use of the duplex scan to rule out carotid arterial disease for patients with vague, uncommon symptoms is inappropriate and wasteful.